MEDICARE: WHITE PEAK DENTAL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1154963098
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WHITE PEAK DENTAL

Provider Business Mailing Address
First Line	:	6800 S HIGHLAND DR STE 100
Second Line	:
City	:	COTTONWOOD HEIGHTS
State	:	UT
Zip	:	84121-3067
Country	:	US
Telephone Number	:	801-293-1234
Fax Number	:	801-305-3683

Provider Business Practice Location Address
First Line	:	6800 S HIGHLAND DR STE 100
Second Line	:
City	:	COTTONWOOD HEIGHTS
State	:	UT
Zip	:	84121-3067
Country	:	US
Telephone Number	:	801-293-1234
Fax Number	:	801-305-3683

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. JUSTIN DOUGLAS HANSEN
Credential	:	DMD
Telephone Number	:	801-293-1234

Provider Enumeration Date	:	10/11/2019
Last Update Date	:	10/11/2019

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